Electronic Funds Transfer (EFT) Authorization Agreement
for Group Premium Billing
I hereby authorize Blue Cross Blue Shield of North Dakota to initiate debit entries and to initiate, if
necessary, credit entries and adjustments for any debit entries in error to my account listed below.
This authority will remain in effect until Blue Cross Blue Shield of North Dakota has received
written notication of its termination at least 30 days prior to the effective date. You must complete
bank information below and attach a copy of a cancelled or voided check to verify account and
routing/transit numbers. Payment withdrawals from your bank account will be completed on the
of the month. Billing schedule is subject to change due to holidays and weekends.
Client Name _______________________________________ Bill Account Number
Telephone Number
Bank Information
Financial Institution Name
Transit/ABA Number
Account Number_______________________________________ Type: Checking Savings
Requested Billing Week: __________________ Requested Effective Date: _________________
Authorized Signature Date
Original - Membership Department Yellow Copy - Your Records
Street or PO Box City State Zip
4510 13th Avenue South
Fargo, North Dakota 58121
29316104 POD (6241) 01-19
City/State Zip Telephone Number